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Tendon Transfer / Lengthening for Children with Cerebral Palsy

What is Tendon Transfer or Lengthening for Children with Cerebral Palsy?

Tendons are bands of tissue that help attach muscles to bones. Tendons and muscles function as one unit, making it possible for our bodies to move.

Cerebral palsy can make muscles and tendons tight. This tightness, also called a contracture, may shorten the muscles and tendons over time. This condition commonly affects the lower extremities. It can cause pain and create abnormalities in the tendons and muscles that affect a child’s mobility.

If your child has contractures, the care team will provide a careful assessment and create a customized treatment plan. The first lines of treatment typically include medication, leg braces, a splint, physical therapy or a combination of these therapies. If nonsurgical therapies don’t treat the contractures effectively, orthopaedic surgery may be the next step.

Two of the most common surgeries for contractures are tendon transfers and muscle lengthening procedures. These can help:

  • Increase range of motion
  • Make sitting, standing and walking more comfortable
  • Reduce pain

Your child’s pediatric orthopaedic surgeon will customize the surgery depending on your child’s needs and goals. The surgeon may recommend doing more than one orthopaedic procedure at a time. When this happens, it’s called a single-event multilevel surgery (SEMLS). SEMLS usually results in fewer total surgeries and only one course of rehabilitation. It can involve surgery for the hip, knee and ankle.

In addition to helping children with cerebral palsy, tendon transfer / lengthening surgeries can treat conditions such as a birth abnormality, clubfoot or walking on toes past the age of 3.

When to Have Tendon Transfer / Lengthening for Cerebral Palsy

In general children should have tendon transfer / lengthening surgery before their bones fully mature. Often the best age is between 6 and 10 years old. A skilled and experienced orthopaedic surgeon carefully evaluates your child to ensure that the right surgery happens at the right time for the best possible outcome.

Types of Tendon Transfer / Lengthening Surgeries

Orthopaedic surgeons offer a wide variety of techniques for tendon transfers and muscle lengthening procedures. Some of these techniques were invented and perfected by pediatric orthopaedic specialists at Cincinnati Children’s.

Orthopaedic surgeries for contractures typically target the following muscles and tendons:

  • Gastrocnemius / soleus complex (calf area)
  • Hip flexor complex
  • Tendons around the foot
  • Hamstring complex (back of the thigh)
  • Rectus femoris complex (near the knee)

Gastrocnemius / Soleus Complex (Calf Area)

The Achilles tendon connects the muscles in the back of the calf (gastrocnemius and soleus muscles) to the heel bone. Contractures can make these calf muscles too tight, causing pain and problems with walking. It may also cause your child to walk on tiptoes, which is typical for young walkers. Toe walking after age 3 may be a concern and is a reason for medical consultation.

During the procedure, the pediatric orthopaedic surgeon lengthens the muscle to help correct the position of the foot and ankle. This is carefully controlled to dial in the “right” amount of correction and may involve using several techniques.

The goal of this surgery is for your child to walk with heels on the floor and knees straight.

Hip Flexor Complex

The hip flexor tendon connects two inner hip muscles (the iliacus and psoas major) to the thigh bone. The tendon helps a child to bend at the hips, sit, stand and walk. If the muscles are tight, it can start to pull the femur (thigh bone) away from the hip, affecting how the child walks.

During the procedure, the surgeon makes a small cut at the front of the hip. Then the surgeon makes incisions in the hip flexor muscle and carefully lengthens it.

Tendons Around the Foot

Some children with cerebral palsy can’t control their foot muscles very well, and their foot may point inward. Surgery on tendons around the foot can help improve positioning and function.

This surgery involves splitting a tendon into two long sections and re-attaching one section to the muscles on the outside of the foot. The “split tendons” act like a stirrup, allowing the foot to maintain a more natural position and function better. This surgery can be a better option than just lengthening or cutting the tendon.

Hamstring Complex

Hamstring tendons connect the hamstring muscles to the pelvis, knee and shin bones. When the tendons are too short and tight, they can cause pain and problems with walking and sitting. Tendon transfer and / or muscle lengthening enable your child to extend and straighten the knee. This makes walking and sitting more comfortable.

The surgeon makes a small incision on the inside of the knee. Hamstring lengthening is more common than tendon transfer, but sometimes a tendon transfer may be beneficial. Your child’s surgeon will discuss the options with you as part of the treatment planning process.

Rectus Femoris Complex

The rectus femoris complex is located in the front of the leg. It allows the knee to straighten and the hip to bend. Contractures in the rectus femoris complex can make the muscles around the knee too stiff. This may cause problems with walking, including tripping.

Tendon transfer surgery involves removing the rectus femoris tendon from the top of the kneecap. The tendon is then transferred and reattached to a muscle on the inside back of the leg, just above the knee.

This allows the rectus femoris muscle to bend the knee instead of straightening the knee.

What to Expect Before Surgery

Your child will have a complete exam. It may include X-rays, advanced imaging studies and a motion analysis study. A motion analysis study is especially helpful. It pinpoints the underlying causes of your child’s walking difficulties, which helps the care team identify which therapies will provide the most benefit.

The orthopaedic surgeon will discuss the test results with you and explain which surgical techniques will be the most effective.

What to Expect After Surgery

Most children return home after one or two days in the hospital, unless combined with other surgery. The care team will help you know what to expect.

After the surgery, your child will probably be able to get up and move around as usual right away (unless the child has other procedures which limit weight bearing). Pain and discomfort are common after tendon transfer / lengthening surgeries, but the care team will help manage it.

Physical therapy is essential for the healing process and a good outcome. Your child’s care team will talk to you about when your child should begin physical therapy, how often sessions should occur and how long to continue. Most children have physical therapy for six to 12 weeks after these surgeries. Your child may wear a brace or cast as part of the recovery process.

Your child probably will be able to return to school within two to four weeks after surgery.


For children with cerebral palsy who have a tendon transfer / lengthening surgery, the outcomes are very good. Nearly all children experience noticeable improvement in range of motion, and long-term outcomes are excellent. This is especially true when a child’s recovery plan includes physical therapy and bracing.

Last Updated 03/2023

Reviewed By Kathy Jaeger, RN

Conditions and treatments.

The Orthopaedic CP Clinic in the Cerebral Palsy Program provides surgical solutions to maximize your child’s ability to walk.